Aims

Whether a combined anteroposterior fusion or a posterior-only fusion is more effective in the management of patients with Scheuermann’s kyphosis remains controversial. The aim of this study was to compare the radiological and clinical outcomes of these surgical approaches, and to evaluate the postoperative complications with the hypothesis that proximal junctional kyphosis would be more common in one-stage posterior-only fusion.

We evaluated the efficacy of anterior fusion alone compared with combined anterior and posterior fusion for the treatment of degenerative cervical kyphosis. Anterior fusion alone was undertaken in 15 patients (group A) and combined anterior and posterior fusion was carried out in a further 15 (group B). The degree and maintenance of the angle of correction, the incidence of graft subsidence, degeneration at adjacent levels and the rate of fusion were assessed radiologically and clinically and the rate of complications recorded. The mean angle of correction in group B was significantly higher than in group A (p = 0.0009). The mean visual analogue scale and the neck disability index in group B was better than in group A (p = 0.043, 0.0006). The mean operation time and the blood loss in B were greater than in group A (p < 0.0001, 0.037). Pseudarthrosis, subsidence of the cage, and problems related to the hardware were more prevalent in group A than in group B (p = 0.034, 0.025, 0.013). Although the combined procedure resulted in a longer operating time and greater blood loss than with anterior fusion alone, our results suggest that for the treatment of degenerative cervical kyphosis the combined approach leads to better maintenance of sagittal alignment, a higher rate of fusion, a lower incidence of complications and a better clinical outcome

1. Posterior fusion of the spine in scoliosis cannot be relied upon to maintain correction of the curve or to prevent progression of a vicious resistant curve. It can, however, hold to some extent the correction of a mobile curve and the compensation of a fixed curve. 2. Despite generally poor results as assessed radiographically, the clinical improvement is often gratifying. Most patients claim to be greatly improved: the spine feels stronger, there is less fatigue, and balance is better controlled. Moreover, visible deformity may be improved markedly even though the anatomical correction as observed radiographically is slight (Figs. l0 and 11). 3. It is believed that the true cause of relapse is that the bone formed from sliver grafts remains immature for a long time. Even when incorporated with the immature bone of the child's spine or the mature bone of the adult spine, it remains soft and resilient. When subjected to the stresses and strains of weight bearing and gravity, and then to the unnatural forces which initiated or perpetuated the scoliosis, this immature bone undergoes remodelling to Wolff's Law—like the neck of the femur after slipping of the upper femoral epiphysis. The forces that alter the grafted bone are not only lateral forces but also—perhaps more important—rotational forces. There seems to be a definite link between the degree of rotation and the amount of relapse, correction being maintained best when rotation is least

Persistent back pain in the presence of an intact posterior fusion is commonly seen and is often regarded as being psychogenic in origin. This paper discusses five patients, all of whom were chronically disabled by such pain; all five had a confirmed posterior and/or lateral fusion. In each case lateral discography identified the disc within the fused segment as the source of symptoms and pain relief was obtained with an anterior interbody fusion. This source of pain should be considered as a possibility in similar cases of failed back surgery

One hundred and three patients with scoliosis treated by posterior fusion and Harrington instrumentation are reviewed. The fusion technique described does not require added bone. Walking in a localiser plaster is encouraged as soon as the wound is healed, usually two weeks after operation. The results compare satisfactorily with others published. It is concluded that added bone is not necessary unless neural arch defects are present, and that early walking is advantageous and without risk to the correction

Thirteen patients with dystrophic spinal deformities from neurofibromatosis treated by anterior and posterior fusion have been reviewed. The shortest follow-up was five years, the average seven years. Combined fusion produced satisfactory results in patients with a smooth kyphoscoliosis or with scoliosis without kyphosis, but it was unsatisfactory in patients with an angular kyphoscoliosis. Of the five patients with angular kyphoscoliosis, one had a persistent pseudarthrosis after operation and all had progression of the kyphosis despite the treatment. The morbidity rate also was high in this group of patients. Many of the complications were related to soft-tissue manifestations of the disease. It is recommended that very special attention be paid to the dystrophic angular deformity in neurofibromatosis; even anterior and posterior spinal fusion may fail to control its progression

A review is presented of 13 young patients with congenital scoliosis who were treated by epiphysiodesis of part of the vertebral bodies combined with posterior fusion, both on the convex side; the plan was to arrest growth on the convexity which, combined with growth of the concave side, would result in progressive correction of the curve. The first patient was operated on at the age of four years and has now reached skeletal maturity with complete correction of her curve. Several others, still growing, are showing progressive correction. Only three curves, in which kyphosis was more severe than scoliosis, have deteriorated since operation. Although full assessment must await skeletal maturity of all the patients, this approach appears to have sufficient potential to justify an early report

There have been few reports regarding the efficacy of posterior instrumentation alone as surgical treatment for patients with pyogenic spondylitis, thus avoiding the morbidity of anterior surgery. We report the clinical outcomes of six patients with pyogenic spondylitis treated effectively with a single-stage posterior fusion without anterior debridement at a mean follow-up of 2.8 years (2 to 5). Haematological data, including white cell count and level of C-reactive protein, returned to normal in all patients at a mean of 8.2 weeks (7 to 9) after the posterior fusion. Rigid bony fusion between the infected vertebrae was observed in five patients at a mean of 6.3 months (4.5 to 8) post-operatively, with the remaining patient having partial union. Severe back pain was immediately reduced following surgery and the activities of daily living showed a marked improvement. Methicillin-resistant Staphylococcus aureus was detected as the causative organism in four patients. Single-stage posterior fusion may be effective in patients with pyogenic spondylitis who have relatively minor bony destruction

Cervical myelopathy is an uncommon but potentially fatal complication of rheumatoid atlanto-axial subluxation. Computerised myelotomography with three-dimensional reconstruction shows that rheumatoid pannus, together with the odontoid peg, contributes significantly to anterior cervico-medullary compression. These findings were the basis for treatment by transoral anterior decompression and posterior occipitocervical fusion, which removes both bony and soft-tissue causes of compression and allows early mobilisation without major external fixation. We report encouraging results from this combined approach in 14 patients who had progressive neurological deterioration

A prospective study to investigate changes in the rib hump or rib deformity after correction of the lateral curvature in adolescent idiopathic scoliosis is reported. The operative treatment for 47 patients was by a Harrington distraction rod and posterior fusion. Before operation and at follow-up, measurements of the Cobb angle, of vertebral rotation, and of the rib deformity were taken. Despite operative correction of the lateral curve, there was a progression of the rib deformity in 64% of the cases after four years. Correction of the lateral curve may thus have no effect on vertebral rotation and cannot be guaranteed to effect a permanent reduction of the rib hump

Introduction: Surgical management of discogenic low back pain has in the past been limited to spinal fusion. Recently disc arthroplasty has become available. The rationale for disc arthroplasty is that it may avoid the long term consequences of adjacent segment degeneration. Avoidance of long term consequences is of no value unless the short term outcome is at least equivalent between fusion and arthroplasty. Methods: A series of patients with chronic low back pain with concordant lumbar discography and a negative control discogram were surgically treated. Prospective data was collected preoperatively and at regular intervals during the post-operative period for a historical series of combined anterior and posterior lumbar fusion (n =24), a series of SB Charité (DePuy Spine) disc replacements (n =23), and recently, a series of Maverick (Medtronic Sofamor Danek) artificial disc replacements (n =9). Self assessed outcome measures of visual analog pain score (VAS), Low Back Outcome Score (LBOS) and SF12 general health data was obtained at intervals after the surgery. This paper presents the results of the consecutive series that have a minimum of 3 months follow-up. Results: The data for the two groups of arthroplasty was combined and compared to the fusion group. The mean age for the fusion group was 37.6 years and the mean age for the arthroplasty group was 38.6 years. There were 5 compensation cases (20.8 %) in the fusion group and 5 cases (15.6 %) in the arthroplasty group. Both groups had 69% male patients. The mean VAS dropped from 7.5 to 3.7 (p< 0.001) in the arthroplasty group and from 7.3 to 3.5 (p< 0.001) in the fusion group. The mean LBOS improved from 22.0 to 36.5 (p< 0.001) in the arthroplasty group and from 19.6 to 37.1 (p< 0.001) in the fusion group. There was no apparent difference between the clinical improvement in VAS and LBOS (p=0.91 and p=0.45 respectively) for each group. Analysis of the power of the comparison showed an 86% power for comparison of VAS improvement using a clinically important difference (delta) of 1 VAS point and there was 98% power for the LBOS improvement comparison using a clinically important difference (delta) of 10 LBOS points. Complications appeared higher in the arthroplasty group with foraminal encroachment requiring revision in 3 cases and one case of polyethylene failure in the Charité group at 3 years. This case occurred with an 8mm polyethylene insert (since removed from inventory by the manufacturer). Discussion: Disc arthroplasty in the lumbar spine appears to offer similar short term results to that of fusion for chronic low back pain. The surgical complication rate may be higher in the early learning curve of the procedure

Aim: Presentation of the application of the transcervical system of posterior spinal fusion Varigrip in spinal infections showing its rapid and safe application and also its stability to the spinal level where it is applied to.

Patients and Methods: 22 patients (13 men / 9 women) with mean age 50, 6 years (18–79) and mean follow up time is 34,6 months (9–62) were included in our study. In 10 patients the level was in lumbar spine and in 12 in thoracic spine. In their admission 16 patients had neurological deficit and 22 mean pain score according to VAS 8, 4 (6–10). ESR was increased in 14 patients, CRP in 20 and 7 patients had also increased WBC. All 22 patients had increased signal of Tc” and 69Ga in the level of the lesion and also pathological signal in MRI (Tl, T2 and Tl with Gadolinium). All the patients underwent posterior spinal fusion using Varigrip system and 17 of these underwent in the same time somatectomy and anterior fusion.

Results: Pathologic organism was isolated to all the patients. In 20 patients the tissue culture of the lesion isolated the pathologic organism and the other 2 patients came to us with positive blood cultures from other hospitals. 6 months postoperatively 21 patients referred pain score according to VAS 2,4 (1–4) and 1 patient had no improvement (5–7). 1 patient died of PE, another of chest infection and one of head injury. 1 patient had recurrence of the infection in another level, 1 had herpeszoster and 1 had infection of the surgical wound. All the patients had neurological improvement postoperatively.

Conclusions: The method is characterized as safe because of avoidance of the neurological structures. It can be applied also safely to patients with osteoporosis. Its application is rapid so the surgical time is minimum and also it doesn’t need image intensifier during the surgical procedure. It can be applied easily either in thoracic or lumbar spine and it provides stability of the spine.

Study Design: Retrospective study with clinical and radiological evaluation of 15 patients with congenital kyphosis or kyphoscoliosis who underwent anterior instrumented spinal fusion for posterolateral or posterior hemivertebae (HV).

Objective: To evaluate the safety and efficacy of early surgical anterior instrumented fusion with partial preservation of the HV in the treatment of progressive congenital kyphosis in children below the age of 3. We discuss the management of patients presenting with neurological compromise.

Summary of background data: A variety of treatments have been described in the literature for the treatment of congenital kyphosis due to HV. We report the results of our technique.

Materials and Methods: Between 1997 and 2005 we have treated 15 consecutive patients with progressive congenital kyphosis with anterior instrumented fusion and strut grafting. 13 patients had a single posterolateral HV and 2 patients a single posterior HV. Of the 15 patients in the study, 5 were girls and 10 boys. Mean age at surgery was 22 months (range 8–33). Mean follow-up period was 6.8 years. 13 HV were located in the thoracolumbar junction (T10-L2) and 2 in the thoracic spine.

Results: The average operating time was procedure was 150 minutes (range, 130 to 210 minutes). The average blood loss 180 mL (range, 100 to 330 mL), equivalent to a mean external blood volume loss of 15% (range, 11 to 24%).

Preoperative segmental Cobb angle averaging 34 º at last follow up. Compensatory coronal cranial and caudal curves corrected by 50%. The angle of segmental kyphosis averaged 39º (range, 20º to 80º) before surgery and 21 º (range, 11º to 40º) at last follow up. This represents a 43% of improvement of the segmental kyphosis, and a 64% of improvement of the segmental scoliosis at last followup.

One case with initial kyphosis of 80 º continued to progress and required revision anterior and posterior surgery. There were no neurologic complications.

Key points:

In progressive congenital kyphoisis, early diagnosis and aggressive surgical treatment are mandatory for a successful result.

The biomechanical effects on facet joints after posterior fusion remain unclear and seem to be responsible for accelerated degeneration. The following biomechanical study was performed to investigate the effects on the pressure and mobility of neighbouring unfused segments after double level T12-L2 posterior stabilization. The experimental study was performed on eighteen fresh, human, cadaveric thoracolumbal spine specimens. The specimens were cleaned and dissected from muscles and fat with care to preserve bone-ligament units intact. In a specially constructed testing machine the data of the segmental pressure and mobility of adjacent segments above and below the fusion were measured before and after double level T12-L2 posterior stabilization with an internal fixator (Universal Spine System) in flexion, extension, lateral bending, and rotation. For measuring the mobility a motion tracker (3Space Fastrak) and for direct evaluation of the pressure a quartz miniature force transducer was used. Also the bone mineral density of the specimens were measured and showed normal values. In flexion and extension Range of Motion (ROM) of the segment above the double level T12-L2 posterior fusion was significantly increased (p< 0,05). In the adjacent segment below the fusion there was no significant increased mobility after fusion for each moment was applied. The pressure did not show any significant difference, but after posterior fusion in flexion and extension the pressure below the posterior fusion (L2/L3) was decreased and above the fusion (T11/T12) increased. There is evidence that the adjacent segment above a double-level T12-L2 posterior fusion becomes more mobile and leads possibly to an accelerated degeneration in the facet joints due to increased stress at this point. Also the posterior fusion seems to change the load distribution in the facets of adjacent segments. These results could be responsible for symptoms like low back pain after spinal surgery

The operative and anaesthesic technique for 44 patients undergoing posterior spinal fusion with Harrington rod instrumentation for idiopathic scoliosis is described. There were two groups of 21 and 23 patients, matched for diagnosis and status before operation. The management of both groups was similar but in one group anaesthesia with induced hypotension was employed, using a mixture of sodium nitroprusside and trimetaphan. The mean blood loss at operation and after operation in this group was significantly lower than in the other group, with a consequent reduction in the transfusion requirement. No adverse sequelae were observed. All patients showed a drop in haemoglobin concentration after operation, despite clinically adequate blood transfusion.

Posterior lumbar fusion is one of the most frequent procedures in spinal surgery. This study examined which factors predict physician-based outcomes in posterior lumbar fusion within the international spine registry Spine Tango. This study used prospective consecutive hospital based documentation. Between May 2005 and October 2007 720 patients had been treated with posterior lumbar fusion for degenerative disease or spondylolisthesis. McNab criteria as commonly used physician-based outcomes were chosen as dependent outcome variable. We dichotomised the original McNab criteria combining “excellent” with “good” to “good”, and “fair” with “poor” to “poor”. Multivariate logistic regression was performed on following potential predictor-variables: age, gender, main pathology, number of previous spinal surgeries, number of spinal segments of posterior fusion, operation time, surgeon credentials, follow-up interval. Median age was 63 years (range 13–90 yrs) with a female to male ratio of 6.3:3.7. Number of previous spinal surgeries (p< 0.001) and follow-up interval (p< 0.001) were found to be predictors of the dichotomised McNab criteria. Patients without previous spinal surgery showed the highest ratio of “good” to “poor” outcome (80.5%:19.5%). This ratio was almost consistently decreasing with the number of previous spinal surgeries to 40%:60% in patients with more than five previous surgeries. At six and twelve-weeks follow-up outcomes were significantly better than after one year, without significant differences between other follow-up intervals. Other examined co-variables showed no influence on the outcomes. Predictors of physician-based outcomes in posterior lumbar fusion are “number of previous spinal surgeries” and “follow-up interval”. In patients with more than five previous spinal surgeries a higher likelihood of “poor” outcomes should be taken into consideration. A too positive outcome may occur at six or twelve-week’s follow-up

We studied the effects of hyperbaric oxygen (HBO) and zoledronic acid (ZA) on posterior lumbar fusion using a validated animal model. A total of 40 New Zealand white rabbits underwent posterior lumbar fusion at L5–6 with autogenous iliac bone grafting. They were divided randomly into four groups as follows: group 1, control; group 2, HBO (2.4 atm for two hours daily); group 3, local ZA (20 μg of ZA mixed with bone graft); and group 4, combined HBO and local ZA. All the animals were killed six weeks after surgery and the fusion segments were subjected to radiological analysis, manual palpation, biomechanical testing and histological examination. Five rabbits died within two weeks of operation. Thus, 35 rabbits (eight in group 1 and nine in groups 2, 3 and 4) completed the study. The rates of fusion in groups 3 and 4 (p = 0.015) were higher than in group 1 (p < 0.001) in terms of radiological analysis and in group 4 was higher than in group 1 with regard to manual palpation (p = 0.015). We found a statistically significant difference in the biomechanical analysis between groups 1 and 4 (p = 0.024). Histological examination also showed a statistically significant difference between groups 1 and 4 (p = 0.036). Our results suggest that local ZA combined with HBO may improve the success rate in posterior lumbar spinal fusion

Despite the increasing prevalence of sleep apnoea, little information is available regarding its impact on the peri-operative outcome of patients undergoing posterior lumbar fusion. Using a national database, patients who underwent lumbar fusion between 2006 and 2010 were identified, sub-grouped by diagnosis of sleep apnoea and compared. The impact of sleep apnoea on various outcome measures was assessed by regression analysis. The records of 84 655 patients undergoing posterior lumbar fusion were identified and 7.28% (n = 6163) also had a diagnostic code for sleep apnoea. Compared with patients without sleep apnoea, these patients were older, more frequently female, had a higher comorbidity burden and higher rates of peri-operative complications, post-operative mechanical ventilation, blood product transfusion and intensive care. Patients with sleep apnoea also had longer and more costly periods of hospitalisation. . In the regression analysis, sleep apnoea emerged as an independent risk factor for the development of peri-operative complications (odds ratio (OR) 1.50, confidence interval (CI) 1.38;1.62), blood product transfusions (OR 1.12, CI 1.03;1.23), mechanical ventilation (OR 6.97, CI 5.90;8.23), critical care services (OR 1.86, CI 1.71;2.03), prolonged hospitalisation and increased cost (OR 1.28, CI 1.19;1.37; OR 1.10, CI 1.03;1.18). . Patients with sleep apnoea who undergo posterior lumbar fusion pose significant challenges to clinicians. . Cite this article: Bone Joint J 2014;96-B:242–8

Posterior lumbar fusion is a frequently performed procedure in spinal surgery. High percentages of good and excellent results are indicated by physicians. On the other hand patient-based outcomes are reported. Little is known about the correlations of these two assessment types. We aimed at their comparison. The analysis included 1013 patients with degenerative spinal disease or spondylolisthesis from an international spine registry, treated with posterior lumbar fusion. All patients were pre/postop assessed by physician-based McNab criteria (‘excellent’, ‘good’, ‘fair’, ‘poor’). Of these patients, 210 (mean age 61 years; 57% females) were in addition assessed by patient-based Oswestry Disability Index (ODI). The remaining 803 patients (mean age 59 years; 56% females) were assessed by patient-based Core Outcome Measure Index (COMI), including. Visual Analogue Scale (VAS) for back and leg pain as well as verbal self-rating (‘helped a lot’, ‘helped’, ‘helped only little’, ‘didn’t help’, ‘made things worse’). McNab criteria were compared to the Minimal Clinically Important Difference (MCID) in ODI (12.8), in VAS back (1.2) and leg pain (1.6). We investigated the correlations between McNab criteria and these patient-based outcomes. In the ‘excellent’ group as rated by physicians, the proposed MCID was reached in 83% of patients for ODI, in 69% for VAS back and in 83% for VAS leg pain. All patients said the treatment had ‘helped’ or ‘helped a lot’. In the ‘good’ group 56% (ODI), 66% (back pain) and 86% (leg pain) reached the MCID. 96% of patients perceived the treatment as positive. In the ‘fair’ group 37% (ODI), 55% (back pain) and 63% (leg pain) reached the MCID. 49% had positive treatment considerations. The ‘poor’ group revealed 30% (ODI), 35% (back pain) and 44% (leg pain) of patients with reached MCID. Only 15% rated the treatment as positive. The Spearman correlation coefficients between McNab criteria on the one hand and ODI, back and leg pain as well as patients’ verbal self-rating on the other hand were 0.57, 0.37, 0.36 and 0.46 respectively. The comparison of physician and patient-based outcomes showed the highest correlations between McNab criteria and ODI, somewhat weaker correlations with patients’ self-rating and the weakest correlations with back and leg pain. Based on these findings, physicians’ evaluation of patient outcomes can be considered a valuable part of patient assessment, corresponding very well with patients’ perceptions of success or failure of spinal surgery

Displaced fractures of the os calcis involving the subtalar joint frequently cause chronic disability due to subsequent osteoarthritis. Early posterior subtalar fusion may prevent this outcome. We have reviewed forty-seven fractures in forty-three patients at an average of seven years after operation. Over 90 per cent of patients had an excellent, good or satisfactory result